(10/02/15)

Proving lawful U.S. presence is mandatory

Applicants age 18 and older must sign the affidavit on the back of the PTC application and list their valid Colorado driver’s license or ID number on the application. You must have a Colorado State issued driver’s license or ID card before applying for the PTC. See page 9 for more information about lawful presence.

You might qualify for the PTC if you are:• A Colorado resident; and• A single person with total income of less than $12,953; or• A married couple with total combined income of less than $17,460; and• At least 65 years old; or• A surviving spouse at least 58 years old; or• Disabled for all of 2015, regardless of age and have received benefits for the full year.

Read all instructions before completing the application, forms and affidavit. Check your rebate status at www.Colorado.gov/RevenueOnline

COLORADO 2015

Property Tax/Rent/Heat RebatePTC BOOKLET INCLUDES:

Application, Instructions and Affidavit

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Do you qualify for the PTC Rebate?Step 1

Did you live in Colorado from January 1–December 31, 2015? If you visit family out of state, but return to your Colorado home, you are still a Colorado resident.Yes. Continue to STEP 2. No. You do not qualify for the PTC.

Step 2Is your TOTAL income from all sources less than the following? Single $12,953 Married (combined income) $17,460

Yes. Continue to STEP 3. No. You do not qualify for the PTC.Step 3

As of December 31, 2015, did you meet one of the following age limitations? If married, at least one person has to meet the criteria.Age 65 or older.A surviving spouse, age 58 or older. If you were divorced before your spouse died, you are not considered a surviving spouse and must therefore meet one of the other age limitations.A disabled person of any age, who was unable to engage in any substantial gainful activity for medical reasons. You must also have been qualified for full benefits from January 1–December 31, 2015 from a bona fide public or private plan or source, based solely on your disability.

Yes. Continue to STEP 4. No. You do not qualify for the PTC.Step 4

Were you lawfully present in the United States during this year? Applicants age 18 or older must have a valid Colorado driver’s license or ID card, and must supply the number on their PTC application. See page 9 for more information.Yes. Continue to STEP 5. No. You do not qualify for the PTC.

Step 5Did you pay property tax, rent, or heating bills during this PTC period?Yes. Continue to STEP 6. No. You do not qualify for the PTC.

Step 6Were you claimed as a dependant on someone else’s federal income tax return?Yes. You do not qualify for the PTC. No. You qualify. Continue to the application.

When will my rebate be issued?The Colorado PTC rebate is paid on a set schedule based on when your application is processed. For faster delivery, we recommend that you file in January or early February and that you sign up for Direct Deposit (see page 4). This payment schedule is set by law, and we cannot make any exceptions. Please review the following application/payment chart.

Application received, approved, and

processed beforeDirect Deposit Payment Dates

Paper Check Payment Dates

Amount of Each Installment

Payment

Number of Equal

InstallmentsMarch 10, 2016 April 5, 2016 April 15, 2016 1/4 of total rebate 4

June 10, 2016 July 5, 2016 July 15, 2016 1/3 of total rebate 3

September 10, 2016 October 5, 2016 October 15, 2016 1/2 of total rebate 2

December 10, 2016 January 5, 2017 January 15, 2017 Full rebate 1

December 31, 2017 10 weeks after receipt 12 weeks after receipt Full rebate 1

Do not call prior to these datesExample: Mary Jones mails her application on January 20, 2016 and she selects Direct Deposit. She will receive 4 equal payments, one of each being deposited in her account by 4/5/16, 7/5/16, 10/5/16 and 1/5/17. Deadline for filing your applicationApplications for the Colorado PTC rebate for calendar year 2015 must be filed on or before December 31, 2017. Applications received after that date will be denied.

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InstructionsSee publication FYI General 2 for Privacy Act Notice and General 7 for more information about PTC. Enter information for the 2015 calendar year only. Mixing up information from other years will delay or deny your application.

• Names—Enter your legal name as it appears on your driver's license/ID card.• Civil Unions — parties to a Civil Union must file as married.• Physical address — If you did not live at this address for the full year, attach a list of all the places you lived throughout

this year. Be sure to include the dates you lived at each location. • Mailing address — Be certain this is your current mailing address, otherwise you may not receive your rebate. • Driver’s license or ID number and expiration date —The Department might request additional proof of Colorado

residency if your license was not valid for the full year. Visit www.Colorado.gov/revenue for more information.• Email address, if you have one.• Confirm your eligibility by checking the appropriate box. Check only one box. If you check box D, attach a copy of

your disability statement that is less than 90 days old. The statement must be provided by the agency that pays the benefits. Veterans Administration Award letters must show the disability percentage at 50% or more.

• First-time filers must provide proof of full-year Colorado residency. If you did not hold your Colorado driver’s license or ID card from January 1–December 31, 2015, you must attach a copy of your lease or rental agreement.

IncomeLine 1 Medicare: Enter the number of months (1–12) you were covered by Medicare. If your premiums were paid by

Medicaid or if you were not on Medicare, enter 0.Lines 2-6 Income: Enter the gross income you received for each item listed. Do not list only the taxable portion. The gross

amount should be clearly identified on the statement(s) you received from the payor. Do not include Medicare benefits on line 2 if they were paid on your behalf by a third party.

Line 7 Other Income: Review the tables below, and report any income you received from these sources that are not already included on lines 2-6.You must report this income:All Taxable Income Disability PaymentsAlimony Disability Insurance SettlementsInheritance Lottery and Gambling WinningsWorker’s Compensation Life Insurance Distributions (exclude funeral expenses)Commissions Rental Income or Loss (exclude expenses, but not depreciation)Royalties Farm Income or Loss (exclude expenses, but not depreciation)Veterans Benefits AFDC or TANF Received (exclude payments received for dependents)Capital Gains Stock Dividends or Rights (only if reported on federal income tax return)Tier 1 & 2 Railroad Retirement Old Age Pension (OAP)Do not report this income:Child Support Received Welfare Payments Received for Dependent Children (AFDC, etc.)Gifts Home Care Allowances or Adult Foster Care AssistanceColorado PTC Rebates Received Capital Losses or Return of CapitalHeat/Fuel Assistance such as LEAP Income Tax RefundsVeterans Service-connected Disability (permanent)

ExpensesLine 8 Property Tax: Enter the total amount of property tax paid, if any. DO NOT include any supplement/assistance

that was paid by the Senior Homestead Exemption. Include only taxes that you paid in the calendar year 2014.Line 9 Rent: Enter the total rent you paid January 1–December 31, 2015, if any.Line 10 Heat/Fuel: Enter the total heat/fuel expenses you paid to heat your home during 2015, if any. DO NOT include

any heat/fuel expenses that were included in your rent payment.Line 11 Meals: Check the appropriate box to indicate whether your meals were included in your rent. If meals were

included for only part of the time you paid rent, enter how much rent was paid when your meals were included.Line 12 Property Tax Exempt: Check the appropriate box to indicate whether you lived in a property tax exempt home.

If your home was property tax exempt for only part of the year, enter how much rent was paid when your home was property tax exempt.

Line 13 Heat/Fuel: Check the appropriate box to indicate whether your heat/fuel was included in your rent. If heat/fuel was included for only part of the time you paid rent, enter how much rent was paid when your heat/fuel was included.

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Direct DepositFor faster processing of your rebate, enter the routing and account numbers and account type. You are not required to enroll in Direct Deposit, but it is highly recommended. Include hyphens, but do NOT enter spaces or special symbols. We recommend that you contact your financial institution to insure you are using the correct information and that they will honor a direct deposit. See the sample check below to assist you in finding the account and routing numbers.

Intercepted RebatesThe Department will intercept your rebate if you owe back taxes or if you owe a balance to another Colorado government agency. If you are filing a joint return and only one party is responsible for the unpaid debt, you may file a written claim to Injured Spouse Desk, 1375 Sherman St, 240, Denver CO 80261. Claims must include copies of all W-2, W-2G, any 1099 and/or TPQY statements received by both parties. DO NOT attach your claim to this application, it will not be processed.Signature(s)Sign and date your application. Failure to sign and date your application will cause delays and/or denial of your rebate.AffidavitTurn to the back of the application, and complete the affidavit for lawful U.S. presence.Special CircumstancesDisabled Children: Complete the following to calculate the PTC rebate for disabled children:a) enter the total income for the disabled child $b) enter the total income for the household, including the disabled child $c) divide line A by line B, enter the result %

Multiply the amount of property tax, rent, and/or heat/fuel expenses by the amount on line c. This is the child’s portion of the expense.Example: Jim is a disabled child under age 18, who received $6,000 in SSI this year. His parents, who do not qualify for the PTC rebate, earned $8,000 from wages this year. The family pays $3,600 in rent and $300 heat/fuel to heat the home. a) $6,000 b) $14,000 c) 42.9%Line 9 of Jim’s application is $1,544 ($3,600 x 0.429) and line 10 is $129 ($300 x 0.429).

Married Persons: If you were legally married, but never divorced you are still considered married. This is true even if you have a legal separation. If you are married, you MUST include all information about your spouse including all income and expenses he/she had in 2015.Non-married Persons Sharing a Home: If you share a home with another adult and you share the expenses of the home, please note the following:

Property Tax One Owner: Only the owner of the home should enter the property tax amount on their application. If the other person living in the home pays the owner rent, the owner must report the rent as income on line 7 and the renter can report the rent expense on their application on line 9. orJoint Ownership: Each owner may enter the property tax amount they paid on their own application. The amount should be calculated according to their ownership percentage in the property. Enter the appropriate amount on line 8 of each person’s application.Rent and/or Heat/FuelEach qualified person may enter the amount of rent and/or heat/fuel expenses on lines 9 and 10 of their own application.

Example: Bob and Joe share an apartment, and they split expenses. Bob pays 55% and Joe pays 45%. Their rent is $4,800 and their heat/fuel is $400. Bob should list $2,640 on line 9 and $220 on line 10. Joe will list $2,160 on line 9 and $180 on line 10.

Departmental Use Only

Mark here if this application is being filed to correct a previously filed 2015 PTC application.

Last Name First Name M.I. Deceased Date of Birth SSNYourself MM/DD/YYYY

Yes

Spouse, if married MM/DD/YYYY

Yes

Physical address (Must match the address on record for your driver's license/ID card) Phone number( )

City State ZIP Colorado driver's license/ID number Expiration Date (MM/DD/YY)

Mailing Address (if different from physical address) Your email address

City State ZIP Spouse's driver's license/ID number Expiration Date (MM/DD/YY)

If you did not live at the address listed above for all of 2015, you must attach a list of addresses at which you lived during 2015 and the dates you lived at each location.

Check the first box that applies to you or your spouse/partner. If none apply, do not fill out this form because you do not qualify for this rebate.

A Age 65 or older on December 31, 2015.

B A widow or widower at least 58 years of age on December 31, 2015.

C Totally disabled for all of 2015 and received payment of full benefits from Social Security, SSI or the Department of Human Services based solely on such disability.

D Totally disabled for all of 2015 and received payment of full benefits from a bona fide public or private plan or source based solely on such disability. You MUST attach proof of disability (see page 3).

List in the boxes below the TOTAL amount(s) received January through December 2015. If joint, add together the income for both parties before listing the total. DO NOT enter your monthly amounts.

1. Enter the number of months (1-12) you received Medicare during 2015. If your Medicare premiums were paid by Medicaid, enter 0. 1

2. Social Security, SSI and/or A.N.D. benefits 2 0 0

3. Colorado Old Age Pension 3 0 0

4. Private or VA pension payments received 4 0 0

5. Wages, salaries and tips 5 0 0

6. Interest and dividends 6 0 0

7. Other income, Explain 7 0 0

ColoradoProperty Tax/Rent/Heat

Rebate Application

Form 104 PTC (10/02/15) COLORADO DEPARTMENT OF REVENUE Denver, CO 80261-0005 www.TaxColorado.com

(1063) 2015*150104PT19999*

Name Account Number

Enter your 2015 property tax, rent and heat expenses.

0 08. If you paid 2014 property tax in 2015, enter amount here 8

0 09. If you paid rent, enter the total for the year here 9

0 010. If you paid heat or fuel expenses, enter the total for the year here 10

11. Are your meals included in your rent payments?

0 0 No Yes OR Only part of the year enter amount 11

12. Did you pay rent for a property tax exempt unit?

0 0 No Yes OR Only part of the year enter amount 12

13. Was your heat included in your rent payments?

0 0 No Yes OR Only part of the year enter amount 13

14. STATE SALES TAX REFUND If you qualify, your state sales tax refund will be $13 if you are single, or $26 if you file jointly.

DirectDeposit

Routing Number Type: Checking Savings

Account Number

I declare under penalty of perjury in the second degree that to the best of my knowledge and belief the information herein is true, correct and complete. Furthermore, I authorize the Department of Revenue to contact the appropriate agencies to verify any information provided on this form and the agencies are hereby authorized to release such information to the Department of Revenue.

Your Signature Date (MM/DD/YY) Mail to: Colorado Department of Revenue, Denver, CO 80261-0005

Spouse/Partner Signature Date (MM/DD/YY) Prepared by

IMPORTANT — You must also complete and sign the affidavit on page 7.

*150104PT29999* Form 104 PTC (10/02/15) COLORADO DEPARTMENT OF REVENUE Denver, CO 80261-0005 www.TaxColorado.com

Affidavit — Restrictions on Public Benefits

IMPORTANT — Do not forget to sign and attach this form.

Yourself

I, swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one):

1. I am a United States citizen.

2. I am not a United States citizen, but I am a Permanent Resident of the United States.

3. I am not a United States citizen, but I am lawfully present in the United States pursuant to Federal law. If you are not a United States citizen, enter your Alien Registration Number.

A#

If joint, spouse or partner

I, swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one):

1. I am a United States citizen.

2. I am not a United States citizen, but I am a Permanent Resident of the United States.

3. I am not a United States citizen, but I am lawfully present in the United States pursuant to Federal law. If you are not a United States citizen, enter your Alien Registration Number.

A#

I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under §18-8-503, C.R.S. and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.Your Signature Date (MM/DD/YY)

Spouse/Partner Signature Date (MM/DD/YY)

*150104PT39999*

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Special Circumstances (continued)Nursing Home Residents: Persons living in nursing homes or assisted living centers are NOT eligible for the PTC Rebate unless one of the following applies –

• The applicant was in assisted living for only part of the year, and • Before they moved into assisted living they paid rent and/or heat/fuel. In this case, the rebate is based

on 20% of the expenses and 100% of the total income received; or • They paid 2014 property taxes while residing in assisted living during 2015. In this case, they may report

the full amount of property tax paid. or• Only one spouse within a married couple resides in a nursing home/assisted living center. The spouse who

maintains the home may file as a single person to report his/her income and expenses only.

Deceased Persons: Surviving spouses or legal representatives may file a PTC application on behalf of a deceased person. Complete the application as usual. You must mark the box next to the name of the deceased person, and write “DeceaseD” in large letters in the white space above the tax year of the return, write “Filing as surviving spouse” or “Filing as legal representative” after your signature, and attach form DR 0102 and a copy of the death certificate to the return.

Rebate StatusYou must allow a minimum of 12 weeks for us to process your application. To check the status of your PTC rebate we recommend you go to www.Colorado.gov/RevenueOnline Follow these easy steps:

1. Visit www.Colorado.gov/RevenueOnline2. Click the Request Letter ID hyperlink. Fill in the requested information. You will receive the

Letter ID by mail in about 2 weeks.3. After you receive the Letter ID, return to www.Colorado.gov/RevenueOnline4. Click Where’s My Refund.5. Click the down-arrow next to Account Type and select Property Tax/Rent/Heat Rebate.6. SSN is the default setting, or you can click the down-arrow to select ITIN.7. Enter your SSN or ITIN.8. Enter your Letter ID, click OK.

DO NOT call to check your status until April 15, 2016. Please note that the Phone wait times can be very long, and we recommend that you use the Internet instead. The refund status on the Internet provides the most current information available.

Federal Credit and Colorado Insurance ProgramsIndividuals whose income does not exceed certain thresholds and/or have qualifying children may be eligible for a refund resulting from the federal Earned Income Tax Credit (EITC) and/or low-cost health insurance through Child Health Plan Plus (CHP+). You may obtain additional information regarding the EITC online at www.irs.gov or by calling Colorado United Way at 211.

Additional information regarding CHP+ can be found online at http:://www.cchp.org or by calling 1-800-359-1991.

2015 State Sales Tax RefundDue to Colorado's budget surplus and pursuant to Section 20 of Article X of the state constitution, the State of Colorado is required to refund $153.6 million dollars to qualifying Colorado citizens. If you are eligible for a PTC rebate you will automatically receive the State Sales Tax Refund too, but only if you were 18 years of age for the entire year of 2015 (born in 1996 or earlier). This refund will be added to your PTC rebate, which will be paid to you according to the same schedule shown on page 2. PTC Applicants can expect the State Sales Tax Refund portion to be $13 for single persons, and joint filers can expect $26.

To claim the State Sales Tax Refund on Form 104PTC, you must file by April 18, 2016. If you are also filing and income tax return on Form 104, do not claim the State Sales Tax Refund on Form 104 or your PTC rebate will be delayed.

Individuals who were in jail during the period from July 1, 2014 to June 30, 2015 or who are in jail when they file their application may not be eligible to receive the State Sales Tax Refund. If this is the case, we will notify you by mail.Apply OnlineYou can file this application online instead of mailing it. Visit www.Colorado.gov/RevenueOnline and simply answer the questions to help guide you through the application process. Using the online application will help prevent errors or incomplete information, which might otherwise delay your rebate. You must supply an email address to file online.

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STATE OF COLORADO DEPARTMENT OF REVENUE Denver CO 80261-0005

PRSRT STDU.S. POSTAGE

PAIDCOLORADO DEPT

OF REVENUE

Please Read all Instructions Before Completing the Forms.

Do Not Mail Return Until After January 1.

Evidence of Lawful PresenceThe Colorado Property Tax/Rent/Heat (PTC) Rebate is a public benefit. Under Colorado law, individuals who are age 18 years or older and are applying for a public benefit must establish lawful presence in the United States. PTC applicants must complete and sign the form “Affidavit — Restrictions on Public Benefits,” which is part of the 104PTC form in this booklet. Applicants must include on the 104PTC form a valid Colorado driver’s license number or Colorado identification number, if available. On the 104PTC application, the following may be written in the boxes for driver’s license/ID number if the applicant does not have those forms of ID:

• “Military” — U.S. military card or military dependent’s ID card• “Coast” — U.S. Coast Guard Merchant Mariner Card• “Tribal” — Native American Tribal Document• “Other” — Other forms of ID are accepted. See the information below.• “Waiver” — In some circumstances an identification waiver may be obtained.

Applicants may obtain additional information regarding Accepted Forms of Identification and the Waiver Process either online at www.TaxColorado.com or by phone by calling 303-238-7378. PTC applicants who do not have a Colorado driver’s license or ID card number must include with their 104PTC form a photo-quality color copy of any one of the other accepted forms of identification. Documents that are business card size must be enlarged to 200% or twice their original size. Valid driver’s licenses from other states will not be accepted because PTC applicants must be full-year Colorado residents. Note: If you have already obtained a waiver from the identification requirements, you do not need to obtain another waiver. The waiver is already on file with the Colorado Department of Revenue.PTC applications will be denied until the required identification information is submitted and/or the affidavit is completed and submitted.

Forms and Information are Available at these Service Centers: Colorado Springs 2447 N. Union Blvd.Fort Collins 3030 S. College Ave.

Denver 1375 Sherman Street

Grand Junction 222 S. 6th Street, Room 208Pueblo 827 W. 4th St., Suite A

Department of Revenue Phone NumbersAssistance ................................................................................................................................303-238-SERV (7378)Driver's License/ID Card Info ................................................................................................................303-205-5600TTY/TTD Service ..................................................................................................................................800-659-2656

Have you Applied for LEAP?You may receive up to $700 in extra help with your heating bills through LEAP. You may also be eligible to receive free home energy saving services like window caulking and attic insulation. Please call toll free 1-866-HEAT-HELP for more information.